The fact that we'll never prove the efficacy of early treatment doesn't mean it's a bad idea, of course. But absent a big trial, the question becomes, do the known benefits of cholesterol testing outweigh the costs and risks? Right now, the answer is no. Cholesterol screening for kids has some potential benefits—it can identify children who would benefit most from intervention, for instance—but it costs money and could lead to an unnecessary increase in prescription drug use among children. One can easily imagine a scenario in which statins become the standard treatment for kids with high cholesterol—not just because drugs are easier to prescribe (and stick to) than diet and exercise, but also because doctors are inherently biased toward doing something rather than nothing. A prescription for lifestyle changes puts the onus on the patient, but people usually go to their physician hoping that it’s the doctor who will take action.
That’s a real cause for concern. A 10-year-old who’s prescribed a statin could potentially continue taking the drug for another 60 years, with no hope of seeing any benefit for at least half that time. Side effects that might seem small over the course of a few months or a year could be unmasked and amplified over the decades, and we don’t have good data yet on the long-term safety and risk profile of statins for children.
So what convinced the panel that the testing was worthwhile? It's notable that among its 14 members, only five disclosed no conflicts of interest. Peter Kwiterovich, a physician and lipid researcher at Johns Hopkins University School of Medicine who chaired the cholesterol sub-panel, reported having received $150,629 from Pfizer (the maker of the statin Lipitor) last year. He has also reported having ties to nine different pharmaceutical companies, including the makers of the statins Zocor and Crestor, and a company that develops and licenses cholesterol tests.
Kwiterovich did not respond to my request for an interview, but when I asked Daniels if he was troubled by the fact that two-thirds of the panel members had declared conflicts of interest, he insisted that these relationships had not tainted their recommendations. “You will not find any group of people more committed to improving the health of kids,” he said. (Daniels himself has served as a consultant for two companies which make cholesterol-lowering drugs.)
Cholesterol drugs clearly help people with existing heart disease, but their benefits for those without heart trouble remain less clear. In the rush to prevent heart problems, we shouldn't lose sight of the actual finish line. High cholesterol is a risk factor, not a disease. Not everyone who has a heart attack has high cholesterol, and many people with high cholesterol do not go on to get heart disease. Right now, we don't have much evidence that tracking cholesterol earlier in life will change the end results we really care about—heart attacks, strokes and other life-threatening conditions.
Four years ago, the U.S. Preventative Services Task Force evaluated the existing studies and concluded that there was insufficient evidence to recommend for or against routine cholesterol screening for children. There haven't been any sweeping new studies since then, so why did the task force stop short of promoting cholesterol screening for children, while the NHLBI panel endorsed it? According to a pediatrician and dissenting panel member Dimitri Christakis, the divergence comes down to a difference in the way the two groups viewed the evidence.
Most of the NHLBI panelists are practicing physicians who work with individual patients. They’re doctors who are paid and trained to do things. The task force includes researchers with backgrounds in statistics, epidemiology and public health. They’ve crunched population data and seen the harms that can come from seemingly innocuous programs (such as prostate cancer screening). “They really take the approach that in the absence of evidence, it’s best not to do something,” Christakis says. Even in the age of high-tech medicine, the Hippocratic oath offers sage advice—first do no harm.